8/13/2013

Standing up Against Polio in DRC

GOMA, 13 August 2013 (IRIN) - When Linda Lukambo, 21, asked his parents why they had neglected to get him thepolio vaccine, “they told me, ‘we did’. So why have I got polio?” he told IRIN in North Kivu in the Democratic Republic of Congo (DRC). “Maybe they took me for vaccinations, but maybe not for polio.” Lukambo first started having difficulty walking while at a pre-school in Tchambucha Village, near the North Kivu town of Walikale. After six months he was, he says, “still walking a little bit. And then I started to move on my bottom, and then on my knees, and it got worse and worse.” By the time he was in primary school he was “crawling on all fours”.Polio, or poliomyelitis, a highly infectious, viral disease causing paralysis and in some cases death, has been eradicated in most countries through large-scale vaccination programmes. According to the UN Children’s Fund (UNICEF) only Nigeria, Pakistan and Afghanistan still have endemic polio transmission. UNICEF, the largest buyer of children’s vaccines in the world, recommends children receive at least three doses of theoral polio vaccineto ensure full immunity against the disease.DRC is considered an “importation country”, meaning it experiences outbreaks of the disease because of low levels of immunity among the population. Polio eradicationcampaigns face myriad obstacles, including large-scale population displacements caused by DRC’s persistent conflicts, poor access to isolated communities, religious objections to the vaccine and weak infrastructure. In 2007, Lukambo had a series of year-long leg-straightening operations at Goma’s public hospital, paid for by local NGOL´Association Congolaise Debout et Fier. (ACDF). ACDF then provided free leg braces, which enabled him to walk upright. He remembers being “very happy - I did not like the ground,” he said.He has since become the caretaker at the ACDF centre, where polio survivors come for leg brace fittings or to just hang out or sleep over in a non-judgmental environment, as society often treats the disabled with suspicion and prejudice.Learning to walkClaudine Muhombe, 7, from Rugare near Masisi, arrived at the centre in April. She now scampers around the centre’s yard, uses the window frames as a climbing frame, and is quickly discovering how to walk with the aid of crutches and braces, also called callipers.“It’s not difficult to walk,” she told IRIN. “I like walking. My Dad came [in June] to visit. He was very happy when he saw me, and I was happy to see my Dad happy.”Joseph Kay ofStandProud, the international and fundraising arm of ACDF, told IRIN that Claudine’s rapid progress meant she would probably not stay at the centre for long.Learning to walk with the callipers and crutches can take weeks or months, requiring intensive physiotherapy to regain strength and balance. But even then, not all are able to.

"It was difficult to learn to walk with leg braces. It took a lot of time to learn. I had no strength in my lower back"

Lukambo’s transition from crawling on the floor to standing on his feet was not as swift as Claudine’s. After his leg-straightening operations, the wounds from the surgery continued to weep and would not heal. He had to undergo a skin graft, with skin taken from his thighs for his knees.The years of crawling also damaged his hip, and an operation was performed to correct it. When he was finally ready to don callipers, it took nearly four months of daily practice to walk upright.“It was difficult to learn to walk with leg braces. It took a lot of time to learn. I had no strength in my lower back, so I had to wear a corset,” he said.After a few months of walking, the muscles in his lower back recovered and the corset was discarded, but Goma’s broken streets were an “obstacle course.”“It’s something you have to get used to… But I am at the same level now as other people,” Lukambo said.Polio campaigns The first polio vaccination campaigns in the country began in the mid-1980s. At one stage, after no cases were recorded between 2001 and 2005, polio was considered eradicated in DRC.In 2008, after an “epidemiologicalsituation evolvedin the central African region,” resulting in dozens of new infections in the country, the government and donors announced a polio vaccination programme targeting seven million children.

Emmanuel Nomo, UNICEF’s DRC polio team leader, recently told IRIN there had been no registered cases of polio in the country since December 2011.“Authorities, vaccination teams and parents are doing the best they can to reach all children everywhere, including in the Kivus, despite the challenge of insecurity and lacking access,” he said.This August, during the country’s National Immunization Day (NID), officials will hold a second round of vaccinations targeting 1,374,836 children up to five years old in North Kivu and 1,144,750 in South Kivu. According to independent monitoring by the World Health Organization (WHO), 3.5 percent of targeted children in North Kivu were missed in the July first round of vaccinations, while in South Kivu the number was 5 percent.“During the July NID, insecurity - active fighting in some health zones - did not allow the vaccination teams to do their job” in the North Kivu health zones of Kamango, in three health areas in Binza, and three health areas in South Kivu’s Molungu, said Nomo.“Even though the situation remains difficult in both Kivus, the second [round] of the NID is scheduled to take place throughout both provinces,” he said.Nomo said issues with maintaining the cold chain, the system of temperature controls required to keep vaccines potent, were being addressed through the introduction of solar fridges by the government, with support from UNICEF, the Global Alliance for Vaccines and Immunization(GAVI), and the World Bank. Currently, only 30 percent of the country’s health centres have a functioning refrigerator.“Providing good quality vaccines at the beneficiary level remains a challenge,” he said.Calliper productionStandProud (founded in 1998) has established centres in Bunia, Butembo, Goma, Kalemie, Lubumbashi and Kinshasa.“We've made thousands and thousands of callipers. Hard to know exactly how many since 1998, but there are at least 5,000 individuals who have benefited over the years,” Kay said.

"I have made a lot [of leg braces]. I don’t know how many, but many, many, many"

Louis Nwande-Muhala, a calliper technician at the Goma centre, says it takes about two days to construct the custom-made leg braces - if there is electricity and the materials are available. The braces are made of steel, with leather used for the joints and hip support. The workshop also does repairs on braces, which have to deal with the country’s broken streets.Nwande-Muhala’s left leg was paralysed at the age of five, not from polio, but from a quinine injection into his hip muscles, an old treatment for malaria that is still practised by some nurses despite the availability of safer treatments.He first encountered the NGO when he wanted to acquire a leg brace. After being fitted for the brace, he decided to give up his tailoring job to make callipers. “I have made a lot [of leg braces]. I don’t know how many, but many, many, many.”go/rz/cbPost Polio Litaff, Association A.C _APPLAC Mexico

The Polio Crusade

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Who we are?

WHO WE ARE

We are a non-profit civil organization legally incorporated in Mexico City, on January 8, 2004. Our main goal is to spread information on Post-Polio Syndrome by all possible means, and to offer help to any person suffering from Poliomyelitis or Post-Polio Syndrome.

Fortunately, thanks to science and medical research, we know the etiology of Post Polio Syndrome and its different pathological manifestations. This knowledge will help persons who had Poliomyelitis to make decisions to avoid or to delay the first’s signs of Post-Polio.

One of the Post-Polio Association Litaff A.C. goals is to provide information onpreventive medicine through medical articles available by free downloads, organization of conferences and seminars,meditation specialized workshops and access to an excellent Cromotherapy treatment for Post-Polio Syndrome and Fibromyalgia, access to nutrition programs, etc.

One of the multiple goals of our association is to help people suffering from Poliomyelitis sequels, Chronic Fatigue or Fibromyalgia

to modify or to improve their life quality.

We base our advice on the experience of specialists and their medical recommendations. One really important goal always present in our minds is to help and support the family and friends of those who suffer from Post-Polio Syndrome, Fibromyalgia and Chronic Fatigue, because they represent a fundamental support for them. We are able to provide them with reliable information and psychological help.

We are concerned about the architectonic barriers in our cities and we’re working every day to improve and make the movements of any person with a motor incapacity easier. In this regard, we do have a good support from our authorities and from the society. Likewise, we offer some good job opportunities with flexible schedules, so every person has a chance to adapt.

We invite every poliomyelitis survivor, every person suffering from Fibromyalgia and/or Chronic Fatigue to join this association through this page, so we can share our experiences and we can also be able to extend the network of families and friends of Post-Polio Litaff A.C. through its chat room, its discussion forum and its conferences. We invite you too, of course, to benefit of all the advantages we offer.

We do consider that this Website could be a valuable media for spreading all the information gathered on Post-Polio Syndrome and, of course, an excellent way of knowing each person affected and helping each other.

This could be done in different ways: direct economical contribution, professional medical attention, or even by donations of wheel chairs, crutches, scooters, and any aid you could think of.

Any doctor who wishes to join us to help our members, any volunteer who wants to help in the activities that Post Polio Litaff A.C.Organizes every day is absolutely welcome.

Of course, we’re aware of the fact that our goals represent an incredible task. However, we do have great enthusiasm and spirit of solidarity that we are putting at the service of this noble cause, inspired by The Supreme Power that makes it All Possible.

As a Post-Polio survivor, I send this message to all those who suffered from Poliomyelitis. I really want to tell you that you are not alone, we’re numerous persons suffering from this Syndrome and, in the same way we fought the Poliomyelitis in our childhood, we’re going to get together and fight together the battle against this still unknown Syndrome. Together, we will force the world to know about it.

In case you’re already a Post-Polio Syndrome victim, the Post-Polio Association Litaff A.C. is here, so that together we can join ours forces and enthusiasm to get the necessary support.

You are all welcome to become part of the association.

“From this day, let’s try to live one day at a time without forcing ourselves to do more than our body is able to” and let’s live with a positive attitude facing forward this event that we can’t modify now. That’s why accepting it with a positive attitude will help any person suffering from it.

History of Polio

History of polio

In the early 20th century, polio was one of the most feared diseases in industrialized countries, paralysing thousands of children every year. Soon after the introduction of effective vaccines in the 1950s and 1960s however, polio was brought under control and practically eliminated as a public health problem in these countries.

It took somewhat longer for polio to be recognized as a major problem in developing countries. Lameness surveys during the 1970s revealed that the disease was also prevalent in developing countries. As a result, during the 1970s routine immunization was introduced worldwide as part of national immunization programmes, helping to control the disease in many developing countries.

In 1988, when the Global Polio Eradication Initiative began, polio paralysed more than 1000 children worldwide every day. Since then, 2.5 billion children have been immunized against polio thanks to the cooperation of more than 200 countries and 20 million volunteers, backed by an international investment of more than US$ 8 billion.

Today, polio has been eliminated from most of the world and only four countries remain endemic. In 2009, fewer than 2000 cases were reported for the entire year.

Use this interactive timeline to trace the history of polio from 1580 B.C. to the present.

A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

The patient's legs, showing massive enlargement of the right calf and wasting on the left

Questions

1

What is that nature of the acute illness in infancy?

2

What is the nature of the subsequent deterioration?

3

What investigations should be performed?

4

What is the differential diagnosis of the cause of the progressive calf hypertrophy?

Answers

QUESTION 1

An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.

QUESTION 2

A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3

QUESTION 3

Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition

QUESTION 4

The differential diagnosis of the progressive calf hypertrophy is given in the box.